High-risk prostate cancer: brachytherapy more effective than surgery
A recent study published in the journal JAMA clearly showed that brachytherapy in combination with external radiation achieves better results for patients with high-risk prostate cancer compared to radical surgery.
More than 60,000 German men are diagnosed with prostate cancer every year, the majority of whom having organ confined cancer. However, 7 to 10 percent of patients have a high-risk prostate cancer. In these the tumour may have already left the organ, but but restricted to the periprostatic region. Lymph node or bone metastases cannot be detected.
"For these patients, it has been shown that the combination of brachytherapy with external radiation is by far the most effective treatment" Dr. Stephan Neubauer explains. In contrast, surgery is not a good choice in advanced stages. The reason: If the prostate is surgically removed, it is often the case that the tumour will already be located outside the sugical margins, and would continue to grow after the operation. This is not the case with brachytherapy, where marginal areas of the prostate are also included in the radiation. "The probability that the tumour will recur in the prostate area (local recurrence) is therefore much lower after combined brachytherapy than after radical surgery," the prostate specialist said .
Best results for combined radiation treatment
US scientists from the University of California in Los Angeles recently also investigated the question of which therapy is most appropriate for patients with high-risk prostate cancer. They compared the efficacy of surgery, radiation alone and brachytherapy in combination with external radiation therapy in a total of 1809 patients aged 61 years on average. In addition, all irradiated patients received hormone treatment.
The study shows once again that brachytherapy in combination with external radiation leads to the best cure rate in prostate cancer patients with a high risk profile. Thus the mortality rate due to prostate cancer after 5 years was only 3 percent for patients who were treated with brachytherapy in combination with external radiation therapy, compared to 13 percent after external radiation alone and 12 percent after surgery. The risk of metastasis was also lowest in patients who received combined radiotherapy.
HDR afterloading: Better cure rate with fewer side effects
HDR afterloading is a suitable brachytherapy method. A highly active radiation source temporarily drives into previously implanted needles and irradiates the tumor directly on site. The irradiation takes only a few minutes and, depending on the findings, is performed three to four times under short anaesthesia. "By precisely distributing the radiation dose, the tumour can be irradiated without damaging surrounding structures such as the urinary bladder, intestine or sphincter," explains the Cologne specialist. In addition to improved efficacy, this also results in fewer side effects than after surgery. Incontinence (< 2 %) and impotence rates (20-40 %) are significantly lower than after surgical removal of the prostate (10-15 % and 60-100 %, respectively).
West German Prostate Center confirms study data
The West German Prostate Center can confirm the excellent efficacy of HDR afterloading in advanced prostate cancer with its own patient data. "Since 2000, we have performed more than 7.000 brachytherapies. About a quarter of them were patients with high-risk prostate cancer who we treated with afterloading therapy," said Dr. Neubauer. "According to the HAROW study, however, despite demonstrably poorer cure rates, only 18 percent of patients are irradiated with a high-risk tumour but around 65 percent undergo surgery," complains the urologist. However, this will probably change in the future due to the convincing study data on brachytherapy for high-risk prostate cancer.
The West German Prostate Centre is one of the centres with the highest number of cases in Europe and is regarded as a pioneer in the field of brachytherapy in Germany.
Kishan AU, Cook RR, Ciezki JP, et al.: Radical prostatectomy, external beam radiotherapy, or external beam radiotherapy with brachytherapy boost and disease progression and mortality in patients with gleason score 9–10 prostate cancer. JAMA 2018; 319 (9): 896–905